Sleep Disorders and Mental Health in Menopausal Women in Tehran

Background: Sleep complaints are common problems in the general population and insomnia and sleep disorders place significant economic and social burdens on the community. Postmenopausal women are 2.6 to 3.5 times more likely to develop obstructive sleep apnea (OSA) compared to non-menopausal women. In this study, we evaluated sleep disorders and mental health in postmenopausal women. Materials and Methods: This study was a descriptive cross-sectional study and the samples were selected from postmenopausal women above 50 years who had participated in a survey entitled, “Evaluation of Sleep Disorders among Adults in Tehran” in 2017. Cluster sampling method was applied with proportional allocation. A total of 4021 samples were collected, 2075 of which belonged to women. In addition, 174 out of 2075 samples were related to postmenopausal women over the age of 50. The data were analyzed using the statistical package IBM SPSS version 22.0. P-values less than 0.05 were considered significant. Results: In this study, 118 (67.8%) women had insomnia for less than three months, and 23 (13.2%) women had insomnia for more than three months. The prevalence of STOPBANG parameters in this group of postmenopausal women was 37% and significantly related to Body mass index (BMI) and neck circumference at P < 0.001 and 0.006, respectively. There was no significant relationship between social dysfunction and insomnia. However, anxiety in General Health Questionnaire (GHQ) was significantly associated with insomnia, sleepiness, sadness, and irritability. Conclusion: Our results indicate that the impact of insomnia symptoms, OSA comorbidity and mental disorders could extend far beyond. The use of urgent health care and quality of life issues is essential for long-term mental and physical well-being; if there is no treatment in the menopause population, there will be serious mental and physical complications.


INTRODUCTION
Sleep complaints are common problems in the general population. In fact, about 35% of population has difficulty falling asleep, staying asleep, or waking up early and feel tired even after sleep (1). As age advances, the quality and quantity of sleep decrease due to a reduction in the nonrapid eye movement (NREM) sleep (N3 stage or delta-TANAFFOS wave sleep) and rapid eye movement (REM) sleep and also because of increase in sleep disorders (2).
Sleep disorders in women are twice as common as men (2)(3)(4). Although deterioration of sleep quality with age in women may be associated with the aging process, the results of various studies have shown that menopause has an independent effect on sleep problems in this population, regardless of age (5,6). Menopause refers to the permanent cessation of menstruation due to the reduced activity of female sex hormones following the reduced function of ovarian follicles (3,7).
Generally, sex hormones, especially estrogen, play an important role in women's health and sleep quality (8,9).
Additionally, the quality of sleep during post menopause is negatively influenced by the individual's poor perception of her health status, poor sleep quality, anxiety, moodiness, chronic diseases, changes in body temperature, hot flashes, circadian rhythm disorders, increased stress responses, behavioral changes, cultural and racial factors, and even ethnic background (5,10,11).
Studies on the symptoms of postmenopausal women have shown that 20-60% of these women have sleeprelated complaints (8), especially obstructive sleep apnea (OSA) (12). The prevalence of insomnia increases from 38% in premenopausal women to 46-48% in postmenopausal women (2). Meanwhile, OSA seems to be more common in men than women. However, the results of different studies have shown that the prevalence and severity of OSA increases during menopause (13).
According to statistics, postmenopausal women are 2.6 to 3.5 times more likely to develop OSA compared to nonmenopausal women (2,6). In addition, weight gain and reduction in estrogen and progesterone levels during menopause increase the risk of OSA (13). Although both reduction and/or cessation of female sex hormones play an important role in the pathogenesis of OSA, the pathophysiology of their effects remains unknown (14).
Generally, insomnia and sleep disorders place significant economic and social burdens on the community due to reduced productivity, increased risk of accidents, and increased healthcare costs (1,15). Clearly, insomnia reduces an individual's quality of life by reducing their concentration and motivation and increasing daytime fatigue, physical and mental burnout, irritability, and disturbance in interpersonal relationships (10). In addition, various studies have shown that people with poor sleep quality are prone to chronic diseases, such as cardiovascular diseases and diabetes mellitus (16,17). Also, poor sleep quality can increase the risk of falling and decrease mobility and independence among people at older age (15). In this study, cluster sampling method was applied with proportional allocation. A total of 105 clusters were selected from the urban districts of Tehran. Then, the samples were randomly allocated to each class in the clusters. In each cluster, one household was randomly selected as the head of the cluster, and then, ten nearby clusters were systematically selected in a clockwise manner. Finally, in each household, one man and one woman over the age of 18 years were surveyed. A total of 4021 samples were collected, 2075 of which belonged to women. In addition, 174 out of 2075 samples were related to postmenopausal women over the age of 50. Menopause was defined as the absence of menstruation for at least 12 months.
Data were collected using a questionnaire consisting three parts. The first part included data such as snoring, tiredness, obstruction during sleep, hypertension, Body mass index (BMI), neck circumference, age, and gender (STOPBANG). If three or more STOPBANG parameters turn out to be positive, STOPBANG would be considered a positive one. Level of education, history of menopause, and diabetes mellitus were also incorporated within questionnaire items.
Second part "Insomnia Screening Questionnaire (ISQ)" consisted of 18 items with omission of two overlapping questions that were in common with STOPBANG questionnaire. Each item is rated as 1-"never or almost never"; 2-"once or twice a month"; 3-"once or twice a week"; 4-"three or four times a week"; 5-"almost every day".

Reliability of ISQ was assessed by calculating Alpha
Cronbach which was 0.79. Subsequently, all items were investigated and the answers were scored.
The third part of the questionnaire was the Iranian version of the 12-item General Health Questionnaire (GHQ-12). GHQ-12 is used to assess the general health of the adults and detect the subjects at risk of non-psychotic disorders. Individuals with GHQ-12 scores of 5 or higher indicated a "poor mental health status".

Statistical Analyses
The data were analyzed using the statistical package

Ethical Issues
The study was approved by the Ethics Committee of National Research Institute of Tuberculosis and Lung Diseases. In addition, oral consent was obtained from all participants before enrolling in the study.

General Health Quality (GHQ) in Postmenopausal Women
In  examining the health of women during their middle age (21). OSA is the most common type of sleep apnea, which is caused by recurrent episodes of respiratory arrest, resulting from complete or partial obstruction of the upper airways (14). The decrement in estrogen and progesterone during post-menopause likely plays a role in increased risk for OSA; progesterone enhances ventilatory drive and affects dilatory muscles of pharynx (22) and partly mediates these effects through estrogen-dependent receptors (23); hence, the menopausal decline in both these hormones might impact respiration.
The onset of menopause, which is followed by an increase in age and BMI, increases the risk of OSA.
According to multiple studies, OSA is more common in postmenopausal women than non-menopausal women, even after controlling BMI and age (24 postmenopausal years can be achieved by this approach (28).
About half of the patients suffered from mental disorders especially anxiety, depression and poor social performance. There seems to be a remarkable percentage of anxiety in Iranian middle-age women's population which in its turn may also be effective in insomnia of menopausal individuals and vice versa. The association between menopausal status and psychological distress highlights the need for organizing specific mental health services for middle aged women particularly in relation to menopause (28,29).
There are several limitations to our study. First, OSA was assessed based on STOPBANG questionnaire not polysomnography. Next, another limitation of this study is the lack of access to the patients' autonomic symptoms.

CONCLUSION
Our results indicate that the impact of insomnia symptoms, OSA comorbidity and mental disorders could extend far beyond. Receiving urgent health care and maintaining quality of life are essential to long-term mental and physical well-being; if there is no treatment in the menopause population, there will be serious mental and physical complications.